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Migraine: Burden of Disease, Treatment, and Prevention

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Migraine: Burden of Disease, Treatment, and Prevention Osteopathic Family Physician (2013) 5, 116–122 Migraine: Burden of disease, treatment, and prevention Natasha N. Bray, DO,a Aaron Heath, DO,b Julietta Militello, DOb From aNova Southeastern University, College of Osteopathic Medicine, Fort Lauderdale, FL; and bBroward Health/Broward Health Medical Center, Fort Lauderdale, FL KEYWORDS: Abstract Migraines are perhaps the most studied of the headache syndromes secondary to the high Migraine; incidence and have significant effect on the quality of life of those suffering from this condition. Headache Despite the high prevalence of migraines, an estimated two-thirds of sufferers either have never consulted a doctor or have stopped doing so. Therefore, it is an underdiagnosed and undertreated condition. The prevalence of migraine attacks is estimated to be 17% in women and 6% in men each year. Evidence-based guidelines for both the immediate treatment as well as preventive therapy have been established. These guidelines outline several management strategies for migraine headaches, including immediately aborting the migraine at the onset of headache, controlling the pain once it has fully evolved, and prophylactic therapy. Abortive treatment should be initiated as soon as an aura or other warning sign is noted. Patient education plays an integral role in any management plan. Headache journals may help patients identify and avoid migraine triggers and document the response to therapeutic intervention. Physicians must be aware of warning signs that may reflect more severe underlying pathology and when neuroimaging, neurology consultation, and hospitalization are warranted. Published by Elsevier Inc. Migraine prevalence and disease burden those older than 60 years of age (Figure 1). In both men and women, prevalence is significantly higher in whites than in The World Health Organization has estimated that over 300 blacks.3 million people worldwide suffer from migraines. The The World Health Organization lists severe migraines American Migraine Prevalence and Prevention study along with quadriplegia, psychosis, and dementia, as one of estimates that the prevalence of migraine attacks is 17% in the most disabling chronic disorders.4 Migraines constitute women and 6% in men each year.1 In the United States, the approximately 16% of the primary headaches. Approx- ratio of females to males suffering from migraines is 2:1.2 In imately 90% of the patients who experience migraines have childhood, migraines affect boys and girls equally. This moderate to severe pain, 75% have decreased ability to trend continues until puberty, when the predominance shifts function during their headache attacks and 33% require bed to women. Peak incidence of migraines occurs between the rest during an attack.1 ages of 30 and 39. Approximately 30% of the people in this The American Migraine Prevalence and Prevention study age range are affected by migraines, of which 24% are of more than 160,000 patients found that a large majority of women and 7% men. Prevalence of migraines is lowest in patients who suffer from migraine headaches had 1-4 headaches per month (62.7%). About 54% of the patients Corresponding author: Natasha N. Bray, DO, Nova Southeastern reported severe impairment or need for bed rest during University, College of Osteopathic Medicine, 3200 S. University Drive, attacks and only about 7% of the patients reported no Fort Lauderdale, FL 33328. 1 E-mail address: [email protected] significant impairment during episodes. 1877-573X/$ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.osfp.2013.01.004 Bray et al. Migraine 117 Migraine Prevalence Based on Age and Sex 30 25 24.4 22.2 20 17.3 15 16 % 10 7.4 6.4 6.5 5 5 5 5 4 1.6 0 12 to 17 18 to 29 30 to 39 40 to 49 50 to 59 >60 Females Males Figure 1 Prevalence of migraine headaches in the United States based on age and sex. Peak incidence of migraines occurs between the ages of 30 and 39. Prevalence is lowest in those older than 60 years of age. Adapted with permission from: Lipton et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68;343.1 Of migraine sufferers, approximately 10.8% of the chocolate. Nitrates and nitrites, monosodium glutamate, patients report 1 attack per week, whereas 14.4% report aspartate, dairy products, and fatty foods; 1 or more per week.2 Onset of pain is usually gradual, sudden drop in estrogen levels associated with menses, followed by a crescendo pattern with slow but ultimately a pregnancy, and oral contraception; complete resolution. Mean duration of headache is 24 hours. stress; The majority of patients report unilateral migraines that are infections, especially in the head and neck; associated with pulsatile pain, light sensitivity, sound sensi- trauma or surgery; tivity, and nausea. Approximately 60%-70% of the migraine medications; sufferers report a prodrome, whereas 20% experience an aura exercise; prior to headache attack2 (Table 1). Prodromes, as opposed to changes in weather or climate; auras, consist of the occurrence of euphoria, depression, strong odors including cigarette smoke and pollutants; and fatigue, hypomania, food cravings, dizziness, cognitive slow- irregular sleep habits, bright sunlight, or flickering lights. ing, or asthenia that occurs up to 24 hours before headache. Migraine therapy Migraine triggers The American Academy of Family Physicians, the Amer- ican College of Physicians-American Society of Internal Migraines often have a triggering event. A headache diary helps Medicine, and the American College of Neurology have to identify factors that may precipitate migraines. Common migraine triggers include but are not limited to the following6,7: established guidelines for the management of migraine headaches.8,9 Though these guidelines differ in some Diet, caffeine excess, or withdrawal and foods that respect, nonsteroidal anti-inflammatory drugs (NSAIDs) contain phenylethylamines, tyramines, and xanthines are uniformly recommended as first-line therapy. In those including aged cheeses, red wine, beer champagne, and patients who fail to respond to NSAIDs or combination analgesics including aspirin plus acetaminophen and caffeine, Table 1 Common migraine symptoms a migraine-specific medication (triptans, dihydroergotamine Migraine symptoms Total (%) [DHE]) should be recommended. There are several strategies in approaching the treatment Pulsatile pain 85 of migraine headaches: immediately aborting the migraine at Unilateral pain 60 onset of headache, controlling the pain once it has fully Same side always affected 20 evolved, and prophylactic therapy. Light sensitivity 80 Therapeutic considerations in tailoring medication regi- Sound sensitivity 76 men include side effects, comorbidities, pregnancy, and Nausea 73 route of administration. Prodrome 60-70 Aura 20 Migraine nonspecific therapy Adapted with permission from: Lipton RB et al. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache. 2001;41:646-657.2 Abortive treatment should be initiated as soon as an aura, prodrome, or pain is noted. 118 Osteopathic Family Physician, Vol 5, No 3, May/June 2013 NSAIDs are indicated as the first-line treatment of choice ergotamine preparation. Caution should also be used with for migraine attacks because of safety, wide availability, selective serotonin reuptake inhibitors (SSRIs) and triptans tolerability, and low side-effect profile. Strong evidence because of the increased risk of serotonin syndrome. exists for the treatment of acute migraine with the NSAIDs DHE 45 is a potent cranial and peripheral vasoconstric- and the combination of acetaminophen plus aspirin and tor. It is available in IV, intramuscular, subcutaneous, and caffeine.9 intranasal forms. The IV form is usually administered in In patients who present with migraine accompanied by combination with an antiemetic drug (ie, metoclopramide). nausea and vomiting, a nonoral route of administration is Intranasal DHE 45 has also been safe and effective as preferred and antiemetics should be considered. Such monotherapy in the short-term treatment of migraines. DHE therapies include intravenous (IV) metoclopramide, IV or 45 is contraindicated in patients with ischemic heart disease, intramuscular prochlorperazine. IV diphenhydramine is hypertension, in combination with MAOI, and in the sometimes given in conjunction with these drugs to prevent elderly.15 akathisia and acute dystonic reactions. Oral antiemetics should not be considered as monotherapy.8,9 In severe migraine, rescue medications including Migraine preventive therapy opioids and butalbitol may be effective. Short-term therapy All patients suffering from migraines should be evaluated for with any of these regimens should be limited to a use of preventive therapy. Despite the large number of maximum of 2 times per week, as overuse of these patients that would benefit from preventative therapy, only a medications has been associated with drug-induced head- small percentage of patients receive it. It is believed that 40% ache. In these patients preventive therapy should be 10 of the people who get migraines would benefit from considered. Although commonly prescribed, there are preventative medication, yet only 12.4% of the adults with few studies documenting the effectiveness of opioids for 16 migraines take preventative medication. Prevention begins the treatment of migraines. Because of the high potential with limiting triggers associated with the onset of migraines for abuse
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